I 

114TH CONGRESS 

1ST SESSION H. R. 4227 

To enhance beneficiary and provider protections and improve transparency 

in the Medicare Advantage market, and for other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 10, 2015 

Ms. DELAURO introduced the following bill; which was referred to the Committee on Ways and Means, and in addition to the Committee on Energy 

and Commerce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned 

A BILL 

To enhance beneficiary and provider protections and improve 

transparency in the Medicare Advantage market, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Medicare Advantage 

5 Bill of Rights Act of 2015’’. 


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1 SEC. 2. LIMITATION ON REMOVAL OF MEDICARE ADVAN2 TAGE PROVIDERS BY MA ORGANIZATIONS. 

3 (a) LIMITATION.—Section 1852(d) of the Social Se4 curity Act (42 U.S.C. 1395w–22(d)) is amended by adding 

5 at the end the following: 

6 ‘‘(7) LIMITATION ON REMOVAL OF PROVIDERS

7 FROM MA PLANS BY MA ORGANIZATIONS.— 

8 ‘‘(A) REMOVAL OF PROVIDERS WITH

9 CAUSE.—Beginning with plan year 2017, except 

10 as provided in subparagraph (C), an MA orga11 nization offering an MA plan may only remove 

12 a provider of services or a supplier from a net13 work of such plan if the organization has cause 

14 to remove such provider or supplier. 

15 ‘‘(B) CAUSE TO REMOVE PROVIDERS.— 

16 ‘‘(i) IN GENERAL.—An MA organiza17 tion offering an MA plan has cause to re18 move a provider of services or a supplier 

19 from a network of such plan if the Sec20 retary determines that the provider or sup21 plier is— 

22 ‘‘(I) medically negligent; 

23 ‘‘(II) in violation of any legal or 

24 contractual requirement applicable to 

25 the provider or supplier acting within 

26 the lawful scope of practice, including 


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1 any participation or other requirement 

2 applicable to such provider or supplier 

3 under this title or under any contrac4 tual term for such plan; or 

5 ‘‘(III) otherwise unfit to furnish 

6 items and services in accordance with 

7 requirements of this title. 

8 ‘‘(ii) CONSIDERATION OF COST TO MA

9 ORGANIZATIONS.—For purposes of sub10 paragraph (A), cost to an MA organization 

11 offering an MA plan due to the participa12 tion of a provider of services or supplier in 

13 a network of such plan does not constitute 

14 cause for the MA organization to remove 

15 such provider or supplier from the network 

16 mid-year, and such cost may not be consid17 ered as a factor in favor of a determination 

18 that such organization has cause to remove 

19 the provider. 

20 ‘‘(C) EXCEPTION.—With respect to each 

21 upcoming plan year, beginning with plan year 

22 2017, an MA organization offering an MA plan 

23 may only remove a provider of services or sup24 plier from a network of such plan for reasons 

25 not specified in subparagraph (B)(i) before the 


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1 date that is 60 days before the first day of the 

2 annual coordinated election period for such plan 

3 year under section 1851(e)(3). 

4 ‘‘(D) NOTICE AND APPEAL PROCESS.— 

5 ‘‘(i) IN GENERAL.—Any removal of a 

6 provider of services or supplier from a net7 work of an MA plan may occur only after 

8 the completion of a fair notice and appeal 

9 process that the Secretary shall establish 

10 by regulation. Such process shall require 

11 the MA organization to provide to such 

12 provider or supplier and to the Secretary 

13 an explanation of the reason or reasons for 

14 the removal. 

15 ‘‘(ii) APPLICATION.— 

16 ‘‘(I) APPLICATION OF NEW PROC17 ESS.—In the case of a removal of a 

18 provider of services or supplier from a 

19 network of an MA plan occurring on 

20 or after the effective date published in 

21 a final rule for such fair notice and 

22 appeal process, such process shall 

23 apply in lieu of the process for the 

24 termination or suspension of a pro25 vider contract under section 


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1 422.202(a) of title 42, Code of Fed2 eral Regulations. 

3 ‘‘(II) CONTINUATION OF OLD

4 PROCESS.—In the case of a removal of 

5 a provider of services or supplier from 

6 a network of an MA plan occurring 

7 before such effective date, the process 

8 for the termination or suspension of a 

9 provider contract under section 

10 422.202(a) of title 42, Code of Fed11 eral Regulations, shall apply. 

12 ‘‘(E) PARTICIPANT NOTICE AND PROTEC13 TION.— 

14 ‘‘(i) NOTICE TO PARTICIPANTS OF

15 PROVIDER REMOVAL.—Not less than 60 

16 days before the date on which a provider 

17 of services or supplier is removed from a 

18 network of an MA plan, the MA organiza19 tion offering such plan shall provide writ20 ten notification of the removal to each in21 dividual enrolled in such plan receiving 

22 items or services from the provider or sup23 plier during the plan year in effect on the 

24 date of removal or during the previous 


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1 plan year. Such notification shall include 

2 at the minimum— 

3 ‘‘(I) the names and telephone 

4 numbers of available in-network pro5 viders of services and suppliers offer6 ing items and services that are the 

7 same or similar to the items and serv8 ices offered by the removed provider 

9 or supplier; 

10 ‘‘(II) information regarding the 

11 options available to an individual en12 rolled in such plan to request the con13 tinuation of medical treatment or 

14 therapy with the removed provider or 

15 supplier; and 

16 ‘‘(III) one or more customer serv17 ice telephone numbers that an indi18 vidual enrolled in such plan may ac19 cess to obtain information regarding 

20 changes to the network of the plan. 

21 ‘‘(ii) ANNUAL NOTICE OF CHANGE.— 

22 In addition to providing the notification of 

23 removal as required under clause (i), the 

24 MA organization offering such MA plan 

25 shall include such notification in the anVerDate Sep 11 2014 02:02 Dec 12, 2015 Jkt 059200 PO 00000 Frm 00006 Fmt 6652 Sfmt 6201 E:\BILLS\H4227.IH H4227

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1 nual notice of change for the MA plan for 

2 the upcoming plan year. 

3 ‘‘(iii) CONTINUITY OF CARE.—In any 

4 case in which a provider of services or sup5 plier is removed from a network of an MA 

6 plan, such plan shall ensure that the re7 moval satisfies the continuity of care re8 quirements under paragraph (1)(A) with 

9 respect to each individual enrolled in such 

10 plan receiving items or services from the 

11 provider or supplier during the plan year 

12 in effect on the date of removal or during 

13 the previous plan year. 

14 ‘‘(F) RULE OF CONSTRUCTION.—Nothing 

15 in this paragraph shall be construed as affect16 ing the ability of a provider of services or sup17 plier to decline to participate in a network of an 

18 MA plan. 

19 ‘‘(8) TRANSPARENCY IN MEASURES USED BY

20 MA ORGANIZATIONS TO ESTABLISH OR MODIFY PRO21 VIDER NETWORKS.— 

22 ‘‘(A) IN GENERAL.—Beginning with plan 

23 year 2017, an MA organization offering an MA 

24 plan shall include the information described in 

25 subparagraph (B)— 


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1 ‘‘(i) in the annual bid information 

2 submitted by the MA organization with re3 spect to the MA plan under section 1854; 

4 and 

5 ‘‘(ii) on the Internet Web Site for the 

6 MA plan. 

7 ‘‘(B) INFORMATION DESCRIBED.—The in8 formation described in this subparagraph is the 

9 following: 

10 ‘‘(i) Information regarding the meas11 ures used by the MA organization to estab12 lish or modify the provider network of the 

13 MA plan, including measures of the quality 

14 and efficiency of providers. Such informa15 tion shall include the specifications, meth16 odology, and sample size of such measures. 

17 ‘‘(ii) Other information related to the 

18 establishment or modification of such pro19 vider network that the Secretary deter20 mines appropriate. 

21 ‘‘(C) LIMITATION.—The information de22 scribed in subparagraph (B) shall not include 

23 any individually identifiable information of any 

24 provider or supplier of services.’’. 

25 (b) ENFORCEMENT.— 


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1 (1) SANCTIONS FOR NONCOMPLIANCE.—Section 

2 1857(g)(1) of the Social Security Act (42 U.S.C. 

3 1395w–27(g)(1)) is amended— 

4 (A) in subparagraph (J), by striking ‘‘or’’; 

5 (B) by redesignating subparagraph (K) as 

6 subparagraph (L); 

7 (C) by inserting after subparagraph (J) 

8 the following new subparagraph: 

9 ‘‘(K) fails to comply with sections 

10 1852(d)(7) or 1852(d)(8); or’’; and 

11 (D) in subparagraph (L) (as so redesig12 nated), by striking ‘‘through (J)’’ and inserting 

13 ‘‘through (K)’’. 

14 (2) SANCTIONS NOT APPLICABLE TO PART D.— 

15 Title XVIII of the Social Security Act is amended— 

16 (A) in section 1860D–12(b)(3)(E) (42 

17 U.S.C. 1395w–112(b)(3)(E)), by striking 

18 ‘‘paragraph (1)(F)’’ and inserting ‘‘paragraphs 

19 (1)(F) and (1)(K)’’; and 

20 (B) in section 1894(e)(6)(B) (42 U.S.C. 

21 1395eee(e)(6)(B)), by inserting ‘‘(other than 

22 paragraph (1)(K) of such section)’’ after 

23 ‘‘1857(g)(1)’’. 

24 (c) MEDICARE ADVANTAGE PLAN COMPARE TOOL.— 

25 Not later than one year after the date of enactment of 


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1 this Act, the Secretary of Health and Human Services 

2 shall take such measures as are necessary to ensure that 

3 the Medicare Advantage Compare Tool takes into account 

4 the preferences and utilization needs of such individuals. 

5 SEC. 3. NETWORK ADEQUACY. 

6 (a) IN GENERAL.—Section 1852(d) of the Social Se7 curity Act (42 U.S.C. 1395w–22(d)), as amended by sec8 tion 2, is amended by adding at the end the following: 

9 ‘‘(9) NETWORK ADEQUACY REQUIREMENTS.— 

10 Beginning in plan year 2017, notwithstanding any 

11 other provision of law, the following shall apply: 

12 ‘‘(A) PROVIDER AVAILABILITY.—When es13 tablishing a plan network, a Medicare Advan14 tage organization offering an MA plan shall, 

15 among other factors determined by the Sec16 retary, consider the following: 

17 ‘‘(i) The anticipated enrollment in the 

18 plan. 

19 ‘‘(ii) The expected types of services 

20 provided and utilization of services by en21 rollees under the plan. 

22 ‘‘(iii) The number and types of pro23 viders needed to provide such services. 

24 ‘‘(iv) The number of network pro25 viders who are not accepting new patients. 


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1 ‘‘(v) The location of providers and en2 rollees. 

3 ‘‘(vi) The full-time equivalent avail4 ability of a provider to provide such serv5 ices. 

6 ‘‘(B) PROVISION OF CARE IN A TIMELY

7 MANNER.—A Medicare Advantage organization 

8 offering an MA plan shall ensure that providers 

9 are able to provide services in a timely manner, 

10 as defined by the Secretary, under the plan. 

11 ‘‘(C) APPLICATION OF NETWORK ACCESS

12 ADEQUACY STANDARDS.—In applying the net13 work access adequacy standards pursuant to 

14 paragraph (1), the Secretary shall seek input 

15 from patient advocacy groups, providers of serv16 ices and suppliers, and MA plans under this 

17 part. 

18 ‘‘(D) CERTIFICATION.—Each plan year, a 

19 Medicare Advantage organization shall certify 

20 to the Secretary, with respect to each MA plan 

21 offered by the organization, that the providers, 

22 including specialists and subspecialists, in the 

23 plan network are able to provide the services re24 quired under the organization’s contract with 

25 the Secretary under section 1857 with respect 


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1 to the offering of such plan and to meet the 

2 needs of the enrollees within the plan service 

3 area during the year. 

4 ‘‘(E) ANNUAL REPORTING.—Each plan 

5 year, a Medicare Advantage organization shall 

6 report to the Secretary the following with re7 spect to each MA plan offered by the organiza8 tion: 

9 ‘‘(i) AVERAGE WAIT TIME.—The aver10 age wait time for primary and specialty 

11 care for enrollees under the plan. 

12 ‘‘(ii) UTILIZATION OF OUT OF NET13 WORK PROVIDERS.—The utilization of out14 of-network providers under the plan. 

15 ‘‘(iii) AVERAGE COST PER PATIENT.— 

16 The average annual spending per patient 

17 for primary and specialty care for enrollees 

18 under the plan. 

19 ‘‘(F) CERTIFICATION.—In advance of the 

20 annual, coordinated election period under sec21 tion 1851(e)(3), a Medicare Advantage organi22 zation shall certify to the Secretary the accu23 racy of provider directories for each plan of24 fered by the organization. 


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1 ‘‘(G) NETWORK REVIEW.—The Secretary 

2 shall ensure that the network of each MA plan 

3 offered by a Medicare Advantage organization 

4 meets the network adequacy guidelines estab5 lished under this paragraph and under section 

6 422.112(a)(4) of title 42, Code of Federal Reg7 ulations (or any successor regulation to such 

8 section) at least once every 3 years or when a 

9 material change in network occurs.’’. 

10 (b) ENFORCEMENT.—Section 1857(g)(1)(K) of the 

11 Social Security Act (42 U.S.C. 1395w–27(g)(1)(K)), as 

12 added by section 2(b), is amended by striking ‘‘or 

13 1852(d)(8)’’ and inserting ‘‘, 1852(d)(8), or 1852(d)(9)’’. 

Æ 


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